Impact of Accelerated Seldinger Technique long peripheral catheters on catheter related outcomes: a systematic review and meta-analysis

Impact of Accelerated Seldinger Technique long peripheral catheters on catheter related outcomes: a systematic review and meta-analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Impact of Accelerated Seldinger Technique long peripheral catheters on catheter related outcomes: a systematic review and meta-analysis Wouter Pieteraerens, Brenda van Delft, Annelies Scholliers, Domien Vanhonacker, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5737761/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Managing intravenous therapy in patients with difficult intravenous access (DIVA) often requires the use of midline catheters (MCs) or long peripheral catheters (LPCs). This study aimed to review and meta-analyze catheter-related outcomes of LPCs inserted using the Accelerated Seldinger Technique (AST) in adult DIVA patients, focusing on dwell time, catheter-related infections, thrombosis, infiltration, occlusion, phlebitis and other outcomes. A systematic review was conducted on quantitative studies from 2000 to 2023, sourced from databases including CINAHL, Cochrane Library, Google Scholar and PubMed, to identify studies on adult DIVA patients requiring AST-LPCs. The review adhered to PRISMA guidelines, and the Quality Assessment Tool for Quantitative Studies was used to ensure rigorous evaluation. Of 1017 records initially reviewed, 11 studies were included in the final analysis. The mean dwell time for LPCs ranged from 2.92 (± 0.54) to 17.1 (± 12.3) days. A meta-analysis showed a significant mean difference in dwell time of 1.98 days (± 1.16 to 2.80) in favor of LPCs over short peripheral catheters (p < 0.00001). Reported complications included infiltration (up to 24%), dysfunction (up to 15.7%), thrombosis (up to 15.4%), catheter-related infections (up to 10.2%), occlusion (up to 10.2%) and phlebitis (up to 9.8%). The findings suggest that AST-LPCs may offer greater durability than short peripheral catheters in DIVA patients. While MCs may be more effective for therapies exceeding four weeks, they involve higher procedural complexities. This review highlights the need for high-quality randomized studies comparing AST-LPCs, MCs, and newer catheter-over-needle LPCs to better inform vascular access specialists in managing DIVA patients. Prospero ID : CRD42023425513 Nursing Anesthesiology & Pain Medicine Critical Care & Emergency Medicine Accelerated Seldinger Technique Indwelling time Infection Occlusion Phlebitis Long peripheral catheter Systematic review Nursing Vascular access Figures Figure 1 Figure 2 Figure 3 Background Peripheral intravenous cannulation can be defined as the process of placing a plastic cannula into a vein to infuse intravenous fluids, blood products or peripherally compatible parenteral nutrition and is widely utilized in hospitalized patients. Estimates from hospital admissions indicate that approximately 80% of patients require a peripheral intravenous catheter (PIVC) during their stay 1 . However, high failure rates (30–35%) of these catheters have been reported due to potentially avoidable complications, such as infiltration, extravasation, occlusion, dislodgement and phlebitis 2 , 3 . The placement of a peripheral catheter is an important aspect of patient care, as well as its dwell time in the vein. The dwell time is defined as the interval between insertion and removal 4 . It has been reported that median dwell times range between two to six days, which often proves insufficient to complete the prescribed intravenous therapy fully 5 . Consequently, repeated cannulation attempts are required, leading to additional pain and discomfort for patients, and increasing the risk of needle stick injuries and unintentional blood contact for healthcare workers 6 . Moreover, the estimated placement costs of a single peripheral catheter range from US $ 28 to US $ 35 7,8 . In the case of frequent catheter replacements, this results in higher healthcare costs and elevated risks of venous depletion and potential access exhaustion 9 . Difficult intravenous access (DIVA) occurs in a considerable proportion of the adult (estimated at 10–24%) and pediatric (estimated at 37%) patient populations 10 . DIVA patients often have chronic illnesses, a history of intravenous drug use, obesity, malnourishment, or previous chemotherapy treatments. The modified adult-DIVA scale by van Loon et al. (2019) is frequently used to assess DIVA severity reliably 11 . In DIVA patients, central venous catheters (CVC) present a viable option for short-term (< 1 month) therapy, offering enhanced patient comfort and greater durability compared to multiple peripheral intravenous catheter (PIVC) placements 12 . However, central lines have been associated with potential (systemic) bloodstream infections 13 . Selecting the appropriate vascular access device is important for preventing central line-associated bloodstream infections (CLABSI). Consequently, the placement of central venous catheters (CVC) should be limited to cases with clear medical indications (e.g., when administering veno-irritating medications). In recent years, a novel catheter type, known as the long peripheral catheter (LPC) has been introduced into clinical practice, filling the gap between short peripheral catheters and midline catheters. The tip of the LPC is consistently positioned within the (upper) arm veins, with lengths typically ranging from 8cm (about 3.15 in) to 10cm (about 3.94 in) and gauges ranging from 22 to 18G 14 . There are several methods for inserting an LPC. Some LPCs are inserted using the "catheter over needle" technique, which is similar to the SPC insertion method. Other devices employ the direct Seldinger Technique, also known as the "catheter over guidewire" technique. When using the accelerated Seldinger technique (AST), the introducer needle, guidewire, dilator and catheter are combined into a single device. The process involves placing the needle into the vessel and advancing the guidewire. Subsequently, the dilator and catheter are inserted over the needle and guidewire 14 . AST offers the potential for enhanced safety, a lower risk of complications such as air or wire embolization and contamination, and faster placement compared to the conventional modified Seldinger technique 15 , 16 . Despite their advantages, AST devices have presented challenges in clinical practice, clinical trials, and the development of guidelines and evidence-based recommendations. One significant challenge is the inconsistent nomenclature, which has led to misconceptions about the potential outcomes associated with these types of catheters. However, recent European guidelines have provided clarity by defining long peripheral catheters as devices with lengths ranging from 6 to 15 cm 17 , 18 , 19 . The aim of this systematic review is to comprehensively evaluate the catheter-related outcomes associated with the utilization of the Accelerated Seldinger Technique (AST) for long peripheral catheter insertion in adult patients encountering difficult intravenous access (DIVA). Methods Protocol and registration The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines have been applied for reporting this systematic review 20 . The protocol was prospectively registered at https://www.crd.york.ac.uk/PROSPERO/on24/08/2023 (CRD42023425513). Eligibility criteria Empirical quantitative studies, either prospective or retrospective, evaluating the placement of a long peripheral catheter in adult DIVA patients, using the AST were included. Systematic reviews, case studies and editorials were excluded. Reflecting advancements in vascular access management since 2000, only articles published after January 2000 were considered for inclusion. Pediatric studies were excluded from this review due to the potential variances in outcomes compared to adult populations. Studies investigating the feasibility of administering irritant medications via long peripheral catheters were also omitted. Articles written in either English or Dutch were considered eligible for inclusion. Search strategy and data sources A comprehensive search was performed across multiple databases, including CINAHL, Cochrane Library, Google Scholar, PubMed (January 2000 to October 2023) using both index terms and free text words to identify studies on catheter types for adults with difficult intravenous access. Interventions included 'mini-midline catheter', 'extended dwell peripheral catheter', 'long peripheral catheter', 'midline catheter', and 'midline', combined with the keywords 'Accelerated Seldinger technique' and 'Accelerated seldinger'. Catheter related outcomes were broadly described as ‘outcomes’ and ‘dwell time’ due to the exploratory nature of this review. The detailed search queries for each database, including the use of Boolean operators between the different concepts, are provided in the supplementary material. Study selection Authors WP and BVD individually searched the databases based on the predefined in-and exclusion criteria. The results were exported to the Rayyan software tool and duplicates were removed. Later, the article selection was performed. The starting point for the selection process was a selection based on the title. In the second stage, the abstracts of the relevant titles were screened. Then a full-text screening of the selected articles. To identify additional relevant studies, reference lists of the selected articles were screened in the last stage of this process. Conflicts were resolved by discussion between WP and BVD, KB was consulted when no consensus was found (Fig. 1 ). Data extraction The data extraction process was conducted independently by two authors (WP and BVD) and disagreements were discussed until consensus was reached (refer to Appendix B, C for details). Data on trial reference, purpose, sample size, country, subject characteristics, design, catheter location, success rate and time to successful cannulation were collected. The dwell time of the catheter was the primary outcome. Additionally, secondary catheter-related outcomes, including total complications, planned removals, infections, thrombosis, infiltration, occlusion, phlebitis, dysfunction, and accidental removal, were meticulously collected. If essential data was missing, the authors of the included articles were contacted, including one author who was approached because only median dwell times without a range were reported, preventing the recalculation to mean dwell times 25 . Quality assessment The Quality Assessment Tool for Quantitative Studies was utilized to evaluate the quality of the included studies, a process independently conducted by two authors (WP and BVD), Followed by discussion until consensus was reached in case of disagreements. This instrument assesses criteria including selection bias, study design, confounders, blinding, data collection methodology and participant attrition. All subscales are scored on a scale from one (strong) to three (weak). A paper is deemed to be of strong quality if no weak aspects are identified, while two or more weak ratings indicate weak quality 22 . Data analysis / data synthesis Median dwell times were converted to means to improve the comparability between studies using the formula of Hozo, Djulbegovic & Hozo (2005). For sample sizes greater than 25, they recommend using the median as estimation of the mean. Range/4 was used as an estimation of the standard deviation for studies with sample sizes ranging from 15–70 and range/6 was used for sample sizes greater than 70 23 . The dwell time of the catheter and placement locations were the only parameters that were uniformly reported by all authors enabling a meta-analysis. All included patients had comparable characteristics: adult, difficult intravenous access requiring ultrasound guided (long) peripheral catheter placement. The analysis was conducted using reported or recalculated means, standard deviations, and sample sizes, utilizing a random-effects model. The meta-analysis was performed using Review Manager (RevMan) version 5.4 24 . All catheter-related outcomes were recalculated to percentages by dividing the number of reported complications by the number of included participants in the intervention group and multiplied by 100 to be able to report percentages. Standardized definitions were used to assess the catheter related outcomes of interest (Supplementary File). Results Study selection The separate phases of study selection are shown in the PRISMA flow chart (see Fig. 1 ). A systematic search identified 1017 records including hand searches and reference list screening. Subsequently, 31 duplicates were removed during the first screening step. Of the 986 remaining articles, 121 records were found to meet the inclusion criteria based on title and abstract. 48 articles were sought for retrieval, of which twelve studies were included in the review. One study was excluded in the final step due to the lack of reported dwell times and other complications. Quality appraisal Ten of the included studies had a low quality and one study was of moderate quality based on the Quality assessment tool for quantitative studies (Fig. 2 ) 22 . The primary reasons for the diminished study quality were selection bias and inconsistent data collection methodologies. Blinding was never performed due to the clear visual differences of these catheter types in comparison to conventional short peripheral catheters. Description of included studies Table 1 comprehensively summarizes the studies included. In total, 1871 catheter placements were reported across eleven studies. The review encompassed a variety of study designs, including eight retrospective studies 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , one pilot randomized controlled trial (RCT) 26 and two RCTs 25 , 35 . Geographically, the studies were distributed across different regions, with four studies conducted in the United States of America 25 , 29 , 31 , 34 , two in Denmark 28 , 35 , two in Australia 26 , 32 , two from South Korea 30 , 33 and one study was performed in Italy 27 . Regarding the terminology of the intervention, seven studies referred to the intervention as 'midline catheter' 26 , 28 , 30 , 32 , 31 , 33 , 35 while two studies used 'extended dwell catheter' 25 , 29 and two studies used the term 'long peripheral catheter’ 27 , 34 . The analysis encompassed eleven studies investigating the utilization of various devices for long peripheral catheter (LPC) placements. Among them, eight studies employed the Power Glide Pro™ long peripheral catheter 26 , 27 , 28 , 30 , 32 , 33 , 34 , 35 , using different configurations. The catheters ranged from 22G and 8cm in length to 18G and 10cm in length. Additionally, two studies utilized the Powerwand® long peripheral catheter in both 20G and 6cm long versions and the 10cm-long version 25 , 31 . One study took advantage of the Arrow® Endurance™ long peripheral catheter, using catheters with dimensions ranging from 22G and 8 cm to 18G and 10cm 29 . Among the studies included, nine reported the placement locations of the catheters 25 , 26 , 27 , 29 , 30 , 31 , 32 , 33 , 34 . The basilic vein in the upper arm was cannulated in 36.8–62.5% of the patients, while brachial vein cannulation in the upper arm was performed in 11.5–62.4% of the cases. Additionally, the cephalic vein in the upper arm was cannulated in 0.9–28% of the patients, revealing the diversity in vein selection based on the clinical context and patient anatomy. Eight studies provided data on first attempt success rates for catheter placements, ranging from the lowest reported rate of 72.7% to the highest rate of 93.9% 25,26,27,29,31,32,33,34 . Regarding the temporal demands associated with efficacious cannulation, elucidating perspectives emerge from three distinct investigative studies. The lowest recorded cannulation time was 8.66 minutes 25 , while the highest reported cannulation time was 45 minutes 26 in one study. Catheter-related outcomes A comprehensive summary of all catheter-related outcomes is presented in Table 2 . Dwell Time Dwell times were reported in all studies, with median and mean values used for reporting. Recalculation to means was performed for six studies 25 , 28 , 29 , 31 , 33 , 34 . Mean dwell times ranged from 2.92 (± 0.54) 25 to 17.1 (± 12.3) days 27 . Notably, 38–85% of placed catheters remained in situ until completion of therapy 28 – 32 . A meta-analysis of three randomized studies was performed for dwell time to compare AST-LPCs to peripheral catheters (see Fig. 3 ) 25 , 26 , 29 . The mean difference was 1.98 (CI: 1.16–2.80) in favor of the AST-LPC (p < 0.00001). However, the heterogeneity was very high (I² = 98%). Catheter-related infections Eight studies provided data on catheter-related infections. Four studies reported no infections 26 , 31 , 32 , 33 , while the remaining studies documented infection rates ranging from 0.6–10.2% 34,30,35,28 . Catheter-related thrombosis Eight studies provided data on catheter-related thrombosis rates ranging from 0.5–15.4% 32,33,31,35,34,25,26,30 . One study reported a median time from insertion to deep venous thrombosis of 11 days (IQR 5–14 days) 34 . One study included a monitoring for pulmonary embolism, yet no events were recorded 31 . Infiltration Infiltration rates were assessed across eight studies, with observed values ranging from 0% in a pilot RCT using a 10 cm long catheter to 24% in a RCT using a 6cm long catheter 26 , 34 , 32 , 33 , 31 , 29 , 28 , 25 . Occlusion Catheter occlusion rates were reported in seven studies, ranging from 0.5–10.2% 32,34,33,26,31,29,28 . Phlebitis Phlebitis rates were documented in four studies, with the lowest rate reported at 0.7%, and the highest at 9.8% 34,31,32,26 . Other Outcomes Nine studies presented data regarding catheter-related dysfunction (e.g. Leaking, kinking, catheter migration, dislodgement). The prevalence of dysfunction ranged from 3.6–15.7% 33,26,29,32,28,30,25,31 . Accidental removal was also reported as a reason for premature removal of the catheter in four studies. This complication extended from 4.3–16.2% 32,28, 35 , 30 . One study used five- and twenty-eight-days complication-free survival as an outcome variable and reported that 92.9% of catheters survived at five days, with 65.5% remaining functional until 28 days after placement 30 . Lastly, one study followed up on nerve contact and arterial damage, but no such complications were observed 35 . Discussion In this review, we aimed to comprehensively analyze the existing literature on catheter-related outcomes for long peripheral catheters placed using AST. To the best of our knowledge, this is the first review specifically focusing on this placement method within the adult DIVA population. Our findings indicate that the available literature is limited, with few randomized studies identified. Most studies were of low to moderate quality due to potential selection bias, retrospective designs and inconsistent data collection methodologies. Overall, reported complications were relatively low, with the highest complication rate being 24% for infiltration. Other complications, including catheter-related infections, thrombosis, occlusion, phlebitis, dysfunction, and accidental removal, were reported at rates below 15.7%. Inconsistency in terminology This review underscores the inconsistency in terminology for catheters measuring 6–15 cm in length. European guidelines advocate for the use of the term ‘long peripheral catheters’ for such devices 14 . However, this terminology has not been consistently adopted in scientific discourse, leading to continued ambiguity in catheter terminology. This may account for the reluctance to embrace the term ‘long peripheral catheter’ in post-2021 non-European studies 14 . Establishing a global consensus on this terminology would enhance the clarity and uniformity of research in this domain and serve as a universally accepted reference for vascular access practitioners. Dwell time Midline catheters (exceeding 15cm in length), with a terminal tip situated at the axilla, are recommended for the administration of peripherally compatible intravenous fluids and blood draws requiring a dwell time of four weeks or more 14 . Dwell times surpassing four weeks have also been observed in midline catheters, with Campagna et al. (2018) highlighting an impressive complication-free period of 273 days (median dwell time: 26 days, IQR: 12–37 days) 36 . Jeon et al. (2022) stood out by recording both five-day and 28-day complication-free durations 30 . The overall mean dwell time in this systematic review was 8.91 days (SD: 4.46) resulting in an expected dwell time of 17.83 days (about 2 and a half weeks) in 95% of the cases when adding two times the standard deviation. This suggests that AST-LPCs are potentially suitable for infusing peripherally compatible solutions over an approximate two-week span. However, for peripheral intravenous medication therapies extending beyond 14 days, midline catheters of over 15cm should be the preferred choice. The first five days following insertion are vital for assessing complications potential early LPC failures, as this dwell time aligns with that of a short peripheral catheter 14 . This proposition should be confirmed in further research using this type of devices. The intravenous length of the catheter plays a pivotal role in the longevity of ultrasound-guided peripheral catheters. A recent RCT propose a 2.75 cm benchmark of catheter length inside the vein for clinical use 37 . This guideline favors the use of midline catheters, which, due to their termination in the axillary or subclavian vein, have a lower infiltration rate of just 0.6%, as reported in earlier studies 14 , 38 . Correspondingly, the 6 cm LPC that was included in this review had the lowest dwell time of all catheters with a mean of 2.92 (± 0.54) days and highest infiltration rate of 24% 25 . Catheter-related complications In this systematic analysis, catheter-related infections emerged as a predominant complication across evaluated studies, with the highest rate (10%) documented by one study using an aseptic non-touch technique combined with an exposed probe and sterile ultrasound gel 28 . Various guidelines emphasize protective measures such as probe covers, sterile single-use gel packets, and sterile gloves to minimize contamination risks during catheter placement during catheter placement 39 , 40 ,41 . Notably, a surveillance study adapted CLABSI to Midline catheter-associated bloodstream infections (MLABSI). Instituting MLABSI rates as a quality metric could pave the way for more standardized reporting of this complication. Moreover, having such uniform data would enable rigorous follow-ups and comparative assessments across national and international medical centers, as indicated in previous research 15 ,42 . Catheter-related thrombosis was generally observed at a relatively low rate in this study; however, one study reported a higher incidence, with 15.4% of patients experiencing this complication 30 . Of the total cases, 17 were classified as minor deep venous thrombosis (DVT), and one case involved a major DVT, which required catheter removal. The major DVT rate of 1.1% in this cohort aligns closely with, but is slightly lower than, the 1.4–4.5% DVT rates reported in earlier studies involving midline catheters. 38 ,43 . The review underscores the importance of clear flushing protocols to prevent occlusions, with Bundgaard Madsen et al. (2020) showing a maximum occlusion rate of 10.2%. Standardized flushing protocols including pulsatile flushing technique, incorporating 0.4s pauses in between flushes, with sufficient flushing volume (10ml in adults) as well as positive pressure application while disconnecting syringes is of major importance. Intra-and extraluminal flushing will be facilitated by using this technique but overdose of single push may cause mechanical endothelial injury and should therefore be avoided 44,45 . Midline catheters can mitigate phlebitis due to their placement in vessels with a larger diameter than lower arm veins, promoting hemodilution and reducing chemical phlebitis compared to peripheral catheters 46 . A recent meta-analysis revealed 1.52% phlebitis rates for midline catheters which was lower compared to the 3.41% for PICC catheters 47 . In this systematic review, Marsh et al.'s 2021 pilot RCT indicated 10% of phlebitis cases, with rates for AST-placed long peripheral catheters being half of standard peripheral catheters 26 . It is worth noting that studies involving irritant medication infusions were excluded due to potential higher complication rates. However, a retrospective study, which encompassed 1086 patients receiving vancomycin (4mg/ml), indicated a mere 0.6% phlebitis rate. Given appropriate dilution, ultrasound-guided access, and the right device, it is inferred that vancomycin does not invariably necessitate a central venous catheter, supporting LPC placement 48 . Based on this review we can conclude that given their extended length, specific placement location, and ultrasound-guided insertion, AST-LPCs are likely to offer prolonged dwell times in comparison to short peripheral catheters, potentially reducing prevalent complications. However, their anticipated dwell times remain shorter than midline catheters, underscoring the distinctions between these devices. In selecting the appropriate device for patients, healthcare professionals should employ standardized decision trees to differentiate between midline catheters and AST-LPCs. Future randomized studies should aim to contrast AST-LPCs with midline catheters in controlled environments to clarify their differences. The major advantage of the Accelerated Seldinger Technique (AST) lies in its ability to facilitate a one-handed, single-operator approach, which enhances procedural efficiency and operator control. Additionally, AST minimizes bleeding risks compared to the traditional Seldinger technique. The risk of contamination is also reduced, as is the potential for air or wire embolization, contributing to an overall safer and more streamlined vascular access procedure 30 . Operators might experience a learning curve with this type of devices which can be encompassed by structured training programs and phantom training 25 , 34 . It is imperative for policymakers to include monitoring of bloodstream infections associated with midline catheters (MLABSI) as a quality metric. While these catheters are growing in popularity as alternatives to central lines, thereby minimizing related complications, their routine follow-ups are potentially overlooked 49 . Additionally, innovations in vascular access devices have brought forth the catheter-over-the-needle approach for LPCs. Although shorter in length (e.g., 6.4 cm) than AST-LPCs (8-10cm), these catheters still hold promise for extending dwell times in DIVA patients and curbing complications. Recent reports indicate median dwell times of 5.66 days for these devices 37 . Yet, a direct comparison between them and either AST-LPCs or midline catheters is still pending. Strengths and limitations This systematic review and meta-analysis is the first to specifically examine catheter-related outcomes of AST-placed long peripheral catheters (LPCs) in adult patients, addressing a critical gap in the literature. While a recent review 50 took a broader approach by comparing LPCs with midline catheters using multiple placement techniques, our study focuses exclusively on AST-placed LPCs. This offers a more targeted evaluation of this specific method. Our review adds four additional studies, including one randomized controlled trial and one retrospective cohort study, that were not part of prior analyses. Two of these studies were incorporated into our meta-analysis for dwell time. By not excluding studies based on methodological quality, we provide a comprehensive overview of the potential complications associated with AST-LPCs, which further clarifies the risks and benefits of this approach. Despite the high heterogeneity observed in the included studies, the findings remain valuable in guiding practitioners to select the most appropriate device for each patient, which is crucial for vessel health preservation. With these recent advancements in our understanding of this topic, we can now refine hospital practices, design more precise clinical trials and enhance clinical decision-making to potentially improve patient outcomes. The strengths of this review include the use of a predefined protocol registered in the PROSPERO database, ensuring transparency and adherence to systematic review standards. Two researchers independently conducted the search, selection, data extraction, and quality assessment processes, which improves the reliability of our findings. To minimize selection bias, we conducted an extensive search across four databases spanning 20 years, identifying 1,017 potential studies. This comprehensive approach addresses a significant knowledge gap concerning AST-placed LPCs and offers valuable insights to vascular access specialists as they navigate catheter selection. Nevertheless, some limitations must be considered. Out of the eleven included studies, eight were retrospective, and ten were rated as lower quality, which may introduce bias and affect the overall reliability of our findings. The focus on adult patients limits the applicability of these results to pediatric populations, where catheter-related outcomes may differ significantly. These factors constrain the generalizability of our findings and highlight the need for caution in their interpretation. Therefore, there is a pressing need for larger, high-quality, and randomized studies to validate and expand upon our findings and to provide more definitive guidance for clinical practice. Conclusion This systematic review and meta-analysis revealed a relatively low amount of catheter related complications for AST-placed LPC’s. For DIVA-patients, AST-placed LPCs might present a more enduring alternative to short peripheral catheters. For treatments extending over four weeks or more, conventional midline catheters might be superior to AST-LPCs in performance. Nonetheless, there is a pressing need for high-quality, randomized studies to further delineate the distinctions among AST-LPCs, midline catheters and the newer catheter-over-the-needle LPCs. Declarations Author’s contributions WP & BVD: Conception, design, acquisition, analysis, interpretation of data, writing the manuscript AS, DV, KB, TT: substantial revision of the review and approval of the submitted version. Statements and Declarations The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article Ethical considerations Not applicable Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. Supplemental material Supplemental material for this article is available online. References Mermel LA (2017) Short-term peripheral venous catheter–related bloodstream infections: a systematic review. Clin Infect Dis 65:1757–1762 Helm RE, Klausner JD, Klemperer JD, Flint LM, Huang E (2015) Accepted but unacceptable: peripheral IV catheter failure. J Infus Nurs 38:189–203 Ray-Barruel G, Xu H, Marsh N, Cooke M, Rickard CM (2019) Effectiveness of insertion and maintenance bundles in preventing peripheral intravenous catheter-related complications and bloodstream infection in hospital patients: a systematic review. 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Syst Rev 5:1–0 Armijo-Olivo S, Stiles CR, Hagen NA et al (2012) Assessment of study quality for systematic reviews: a comparison of the Cochrane Collaboration Risk of Bias Tool and the Effective Public Health Practice Project Quality Assessment Tool: methodological research. J Eval Clin Pract 18:12–18 Hozo SP, Djulbegovic B, Hozo I (2005) Estimating the mean and variance from the median, range, and the size of a sample. BMC Med Res Methodol 5:1–10 Review Manager (RevMan) Version 5.4. The Cochrane Collaboration, Available at revman.cochrane.org Bahl A, Hang B, Brackney A et al (2019) Standard long IV catheters versus extended dwell catheters: a randomized comparison of ultrasound-guided catheter survival. Am J Emerg Med 37:715–721 Marsh N, Larsen E, O'Brien C et al (2021) Midline pilot randomised controlled trial: Managing peripheral intravenous devices among adult hospital patients with limited vascular access or prolonged therapy trial. Infect Dis Health 26:S6–7 Fabiani A, Santoro M, Sanson G (2023) The catheter-to-vein ratio at the tip level, not the catheter type, as a risk factor for a catheter failure. A retrospective comparative study of polyurethane midline and long peripheral catheters. Heart Lung 60:39–44 Bundgaard Madsen E, Sloth E, Skov Illum B, Juhl-Olsen P (2020) The clinical performance of midline catheters—An observational study. Acta Anaesthesiol Scand 64:394–399 Fung CM, Stayer DR, Terrasi JJ et al (2021) Extended dwell and standard ultrasound guided peripheral intravenous catheters: Comparison of durability and reliability. Am J Emerg Med 47:267–273 Jeon MH, Kim CS, Han KD, Kim MJ (2022) Efficacy and safety of midline catheters with integrated wire accelerated Seldinger technique. Vasc Spec Int ; 38 Johnson A, Gupta A, Feierabend T et al (2023) Midline catheters: A 3-year experience at a veterans administration medical center. Am J Infect Control 51:563–566 Jones P (2023) Implementation of a midline catheter service in a regional setting. Br J Nurs 32:S38–42 Lee MO, Lee SK, Song YG (2023) Midline Catheters in the Operating Room. Niger J Clin Pract 26:1097–1100 Patel SA, Araujo T, Rodriguez LP et al (2019) Long peripheral catheters: a retrospective review of major complications. J Hosp Med 14:758–760 Nielsen EB, Antonsen L, Mensel C et al (2021) The efficacy of midline catheters—a prospective, randomized, active-controlled study. Int J Infect Dis 102:220–225 Campagna S, Gonella S, Zerla PA et al (2018) The risk of adverse events related to extended-dwell peripheral intravenous access. Infect Control Hosp Epidemiol 39:875–877 Bahl A, Hijazi M, Chen NW et al (2020) Ultralong versus standard long peripheral intravenous catheters: a randomized controlled trial of ultrasonographically guided catheter survival. Ann Emerg Med 76:134–142 Chopra V, Kaatz S, Swaminathan L et al (2019) Variation in use and outcomes related to midline catheters: results from a multicentre pilot study. BMJ Qual Saf 28:714–720 Gorski LA, Hadaway L, Hagle ME et al (2021) Infusion therapy standards of practice. J Infus Nurs 44:S1–224 Moureau N, Gregory EG (2020) Survey of ultrasound-guided peripheral intravenous practices: a report of supply usage and variability between clinical roles and departments. Br J Nurs 29:S30–S38 Thompson J, Garrett JH (2018) Transducer disinfection for evaluation and insertion of peripheral and central catheters for vascular access teams and clinicians. J Assoc Vasc Access 23:141–146 Dawson RB, Moureau NL (2013) Midline catheters: an essential tool in CLABSI reduction. Infect Control Today 3:1–9 Lisova K, Hromadkova J, Pavelková K et al (2018) The incidence of symptomatic upper limb venous thrombosis associated with midline catheter: prospective observation. J Vasc Access 19:492–495 Goossens GA (2015) Flushing and locking of venous catheters: available evidence and evidence deficit. Nurs Res Pract ; 2015: 985686 Zhu L, Liu H, Wang R et al (2020) Mechanism of pulsatile flushing technique for saline injection via a peripheral intravenous catheter. Clin Biomech 80:105103 Adams DZ, Little A, Vinsant C, Khandelwal S (2016) The midline catheter: a clinical review. J Emerg Med 51:252–258 Lu H, Yang Q, Tian B et al (2022) A meta-analysis of the comparison of phlebitis between midline catheters and peripherally inserted central catheters in infusion therapy. Int J Nurs Pract 28:e12976 Caparas JV, Hung HS (2017) Vancomycin administration through a novel midline catheter: summary of a 5-year, 1086-patient experience in an urban community hospital. J Assoc Vasc Access 22:38–41 Hogle NJ, Balzer KM, Ross BG et al (2020) A comparison of the incidence of midline catheter–associated bloodstream infections to that of central line–associated bloodstream infections in 5 acute care hospitals. Am J Infect Control 48:1108–1110 Fabiani A, Aversana N, Santoro M, Sanson G (2024) Complications associated to midline-and long peripheral catheters in adults. Systematic review of literature and proposal for a standardized model for data collection. Thromb Res ; 50 Tables Tables 1 and 2 are available in the Supplementary Files section. Additional Declarations The authors declare no competing interests. Supplementary Files SUPPLEMENTARYMATERIALsearchstrategy.pdf SUPPLEMENTARYMATERIALDefinitionscatheterrelatedoutcomes.docx Tables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5737761","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":414801266,"identity":"e591723e-8c07-4e6a-8cfc-600282a5378e","order_by":0,"name":"Wouter 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Brussel","correspondingAuthor":false,"prefix":"","firstName":"Brenda","middleName":"van","lastName":"Delft","suffix":""},{"id":414801268,"identity":"f7e0c2ad-f1ea-4032-ba23-033154ff445e","order_by":2,"name":"Annelies Scholliers","email":"","orcid":"","institution":"Universitair Ziekenhuis Brussel","correspondingAuthor":false,"prefix":"","firstName":"Annelies","middleName":"","lastName":"Scholliers","suffix":""},{"id":414801269,"identity":"c837d903-275f-4243-8eb1-5ebcb30aee49","order_by":3,"name":"Domien Vanhonacker","email":"","orcid":"","institution":"Universitair Ziekenhuis Brussel","correspondingAuthor":false,"prefix":"","firstName":"Domien","middleName":"","lastName":"Vanhonacker","suffix":""},{"id":414801270,"identity":"9115a21c-2d97-4f28-a7e8-07a2b6517beb","order_by":4,"name":"Tim Torsy","email":"","orcid":"","institution":"Ghent University/Odisee university of applied Sciences","correspondingAuthor":false,"prefix":"","firstName":"Tim","middleName":"","lastName":"Torsy","suffix":""}],"badges":[],"createdAt":"2024-12-30 20:31:13","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-5737761/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5737761/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":76569764,"identity":"e99d4d5d-f993-4bab-89ec-993e1cf07b3a","added_by":"auto","created_at":"2025-02-18 13:25:13","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":62533,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flowchart\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5737761/v1/81eb22dd16f0a6ba34360525.png"},{"id":76569766,"identity":"df215d57-d99b-43a1-8eda-2a348c49dae6","added_by":"auto","created_at":"2025-02-18 13:25:13","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":73951,"visible":true,"origin":"","legend":"\u003cp\u003eRisk of bias assessment\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5737761/v1/685bd6e9759561fcba4fac90.png"},{"id":76569767,"identity":"c9b6bdcd-314a-4baa-ad30-ecefa694c120","added_by":"auto","created_at":"2025-02-18 13:25:13","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":64085,"visible":true,"origin":"","legend":"\u003cp\u003eForest plot dwell time AST vs Peripheral catheter\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5737761/v1/0ec9b3a45980d99acb9af4ef.png"},{"id":76572181,"identity":"a23bb4f6-989c-4784-a54e-121a79ed0dcf","added_by":"auto","created_at":"2025-02-18 13:49:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":874541,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5737761/v1/dd7b5497-6df3-4ea5-9aab-b506cf42671a.pdf"},{"id":76570182,"identity":"7ff4512b-8963-4a04-b07d-65204ef0c9ba","added_by":"auto","created_at":"2025-02-18 13:33:13","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":31745,"visible":true,"origin":"","legend":"","description":"","filename":"SUPPLEMENTARYMATERIALsearchstrategy.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5737761/v1/9be644d5dccab9cfa4fd436a.pdf"},{"id":76570189,"identity":"b2e2ae49-365e-44c5-afe0-642fbd916cc9","added_by":"auto","created_at":"2025-02-18 13:33:13","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":14803,"visible":true,"origin":"","legend":"","description":"","filename":"SUPPLEMENTARYMATERIALDefinitionscatheterrelatedoutcomes.docx","url":"https://assets-eu.researchsquare.com/files/rs-5737761/v1/8d3e4490e4d8871470a35b1f.docx"},{"id":76571699,"identity":"e95841da-a091-4153-83b9-1d58e289fc62","added_by":"auto","created_at":"2025-02-18 13:41:13","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":317358,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-5737761/v1/c2bdaea1e4cf190cbbcfe857.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eImpact of Accelerated Seldinger Technique long peripheral catheters on catheter related outcomes: a systematic review and meta-analysis\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003ePeripheral intravenous cannulation can be defined as the process of placing a plastic cannula into a vein to infuse intravenous fluids, blood products or peripherally compatible parenteral nutrition and is widely utilized in hospitalized patients. Estimates from hospital admissions indicate that approximately 80% of patients require a peripheral intravenous catheter (PIVC) during their stay\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. However, high failure rates (30\u0026ndash;35%) of these catheters have been reported due to potentially avoidable complications, such as infiltration, extravasation, occlusion, dislodgement and phlebitis\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe placement of a peripheral catheter is an important aspect of patient care, as well as its dwell time in the vein. The dwell time is defined as the interval between insertion and removal\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. It has been reported that median dwell times range between two to six days, which often proves insufficient to complete the prescribed intravenous therapy fully\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Consequently, repeated cannulation attempts are required, leading to additional pain and discomfort for patients, and increasing the risk of needle stick injuries and unintentional blood contact for healthcare workers\u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMoreover, the estimated placement costs of a single peripheral catheter range from US\u003cspan\u003e$\u003c/span\u003e28 to US\u003cspan\u003e$\u003c/span\u003e35\u003csup\u003e7,8\u003c/sup\u003e. In the case of frequent catheter replacements, this results in higher healthcare costs and elevated risks of venous depletion and potential access exhaustion\u003csup\u003e \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e9\u003c/span\u003e \u003c/sup\u003e. Difficult intravenous access (DIVA) occurs in a considerable proportion of the adult (estimated at 10\u0026ndash;24%) and pediatric (estimated at 37%) patient populations\u003csup\u003e \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e \u003c/sup\u003e. DIVA patients often have chronic illnesses, a history of intravenous drug use, obesity, malnourishment, or previous chemotherapy treatments. The modified adult-DIVA scale by van Loon et al. (2019) is frequently used to assess DIVA severity reliably\u003csup\u003e \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e \u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn DIVA patients, central venous catheters (CVC) present a viable option for short-term (\u0026lt;\u0026thinsp;1 month) therapy, offering enhanced patient comfort and greater durability compared to multiple peripheral intravenous catheter (PIVC) placements\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. However, central lines have been associated with potential (systemic) bloodstream infections\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Selecting the appropriate vascular access device is important for preventing central line-associated bloodstream infections (CLABSI). Consequently, the placement of central venous catheters (CVC) should be limited to cases with clear medical indications (e.g., when administering veno-irritating medications).\u003c/p\u003e \u003cp\u003eIn recent years, a novel catheter type, known as the long peripheral catheter (LPC) has been introduced into clinical practice, filling the gap between short peripheral catheters and midline catheters. The tip of the LPC is consistently positioned within the (upper) arm veins, with lengths typically ranging from 8cm (about 3.15 in) to 10cm (about 3.94 in) and gauges ranging from 22 to 18G\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. There are several methods for inserting an LPC. Some LPCs are inserted using the \"catheter over needle\" technique, which is similar to the SPC insertion method. Other devices employ the direct Seldinger Technique, also known as the \"catheter over guidewire\" technique. When using the accelerated Seldinger technique (AST), the introducer needle, guidewire, dilator and catheter are combined into a single device. The process involves placing the needle into the vessel and advancing the guidewire. Subsequently, the dilator and catheter are inserted over the needle and guidewire\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. AST offers the potential for enhanced safety, a lower risk of complications such as air or wire embolization and contamination, and faster placement compared to the conventional modified Seldinger technique\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e Despite their advantages, AST devices have presented challenges in clinical practice, clinical trials, and the development of guidelines and evidence-based recommendations. One significant challenge is the inconsistent nomenclature, which has led to misconceptions about the potential outcomes associated with these types of catheters. However, recent European guidelines have provided clarity by defining long peripheral catheters as devices with lengths ranging from 6 to 15 cm\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe aim of this systematic review is to comprehensively evaluate the catheter-related outcomes associated with the utilization of the Accelerated Seldinger Technique (AST) for long peripheral catheter insertion in adult patients encountering difficult intravenous access (DIVA).\u003c/p\u003e"},{"header":"Methods","content":"\u003ch3\u003eProtocol and registration\u003c/h3\u003e\n\u003cp\u003eThe Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines have been applied for reporting this systematic review\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. The protocol was prospectively registered at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.crd.york.ac.uk/PROSPERO/on24/08/2023\u003c/span\u003e\u003cspan address=\"https://www.crd.york.ac.uk/PROSPERO/on24/08/2023\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e (CRD42023425513).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEligibility criteria\u003c/h2\u003e \u003cp\u003eEmpirical quantitative studies, either prospective or retrospective, evaluating the placement of a long peripheral catheter in adult DIVA patients, using the AST were included. Systematic reviews, case studies and editorials were excluded. Reflecting advancements in vascular access management since 2000, only articles published after January 2000 were considered for inclusion. Pediatric studies were excluded from this review due to the potential variances in outcomes compared to adult populations. Studies investigating the feasibility of administering irritant medications via long peripheral catheters were also omitted. Articles written in either English or Dutch were considered eligible for inclusion.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSearch strategy and data sources\u003c/h3\u003e\n\u003cp\u003eA comprehensive search was performed across multiple databases, including CINAHL, Cochrane Library, Google Scholar, PubMed (January 2000 to October 2023) using both index terms and free text words to identify studies on catheter types for adults with difficult intravenous access. Interventions included 'mini-midline catheter', 'extended dwell peripheral catheter', 'long peripheral catheter', 'midline catheter', and 'midline', combined with the keywords 'Accelerated Seldinger technique' and 'Accelerated seldinger'. Catheter related outcomes were broadly described as \u0026lsquo;outcomes\u0026rsquo; and \u0026lsquo;dwell time\u0026rsquo; due to the exploratory nature of this review. The detailed search queries for each database, including the use of Boolean operators between the different concepts, are provided in the supplementary material.\u003c/p\u003e\n\u003ch3\u003eStudy selection\u003c/h3\u003e\n\u003cp\u003eAuthors WP and BVD individually searched the databases based on the predefined in-and exclusion criteria. The results were exported to the Rayyan software tool and duplicates were removed. Later, the article selection was performed. The starting point for the selection process was a selection based on the title. In the second stage, the abstracts of the relevant titles were screened. Then a full-text screening of the selected articles. To identify additional relevant studies, reference lists of the selected articles were screened in the last stage of this process. Conflicts were resolved by discussion between WP and BVD, KB was consulted when no consensus was found (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eData extraction\u003c/h3\u003e\n\u003cp\u003eThe data extraction process was conducted independently by two authors (WP and BVD) and disagreements were discussed until consensus was reached (refer to Appendix B, C for details). Data on trial reference, purpose, sample size, country, subject characteristics, design, catheter location, success rate and time to successful cannulation were collected. The dwell time of the catheter was the primary outcome. Additionally, secondary catheter-related outcomes, including total complications, planned removals, infections, thrombosis, infiltration, occlusion, phlebitis, dysfunction, and accidental removal, were meticulously collected. If essential data was missing, the authors of the included articles were contacted, including one author who was approached because only median dwell times without a range were reported, preventing the recalculation to mean dwell times\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003eQuality assessment\u003c/h3\u003e\n\u003cp\u003e The Quality Assessment Tool for Quantitative Studies was utilized to evaluate the quality of the included studies, a process independently conducted by two authors (WP and BVD), Followed by discussion until consensus was reached in case of disagreements. This instrument assesses criteria including selection bias, study design, confounders, blinding, data collection methodology and participant attrition. All subscales are scored on a scale from one (strong) to three (weak). A paper is deemed to be of strong quality if no weak aspects are identified, while two or more weak ratings indicate weak quality\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis / data synthesis\u003c/h2\u003e \u003cp\u003eMedian dwell times were converted to means to improve the comparability between studies using the formula of Hozo, Djulbegovic \u0026amp; Hozo (2005). For sample sizes greater than 25, they recommend using the median as estimation of the mean. Range/4 was used as an estimation of the standard deviation for studies with sample sizes ranging from 15\u0026ndash;70 and range/6 was used for sample sizes greater than 70\u003csup\u003e23\u003c/sup\u003e. The dwell time of the catheter and placement locations were the only parameters that were uniformly reported by all authors enabling a meta-analysis. All included patients had comparable characteristics: adult, difficult intravenous access requiring ultrasound guided (long) peripheral catheter placement. The analysis was conducted using reported or recalculated means, standard deviations, and sample sizes, utilizing a random-effects model. The meta-analysis was performed using Review Manager (RevMan) version 5.4\u003csup\u003e24\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAll catheter-related outcomes were recalculated to percentages by dividing the number of reported complications by the number of included participants in the intervention group and multiplied by 100 to be able to report percentages.\u003c/p\u003e \u003cp\u003eStandardized definitions were used to assess the catheter related outcomes of interest (Supplementary File).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy selection\u003c/h2\u003e\n \u003cp\u003eThe separate phases of study selection are shown in the PRISMA flow chart (see Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). A systematic search identified 1017 records including hand searches and reference list screening. Subsequently, 31 duplicates were removed during the first screening step. Of the 986 remaining articles, 121 records were found to meet the inclusion criteria based on title and abstract. 48 articles were sought for retrieval, of which twelve studies were included in the review. One study was excluded in the final step due to the lack of reported dwell times and other complications.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eQuality appraisal\u003c/h2\u003e\n \u003cp\u003eTen of the included studies had a low quality and one study was of moderate quality based on the Quality assessment tool for quantitative studies (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. The primary reasons for the diminished study quality were selection bias and inconsistent data collection methodologies. Blinding was never performed due to the clear visual differences of these catheter types in comparison to conventional short peripheral catheters.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eDescription of included studies\u003c/h2\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e comprehensively summarizes the studies included.\u003c/p\u003e\n \u003cp\u003eIn total, 1871 catheter placements were reported across eleven studies. The review encompassed a variety of study designs, including eight retrospective studies \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e, one pilot randomized controlled trial (RCT)\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e and two RCTs\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n \u003cp\u003eGeographically, the studies were distributed across different regions, with four studies conducted in the United States of America\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e, two in Denmark\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e, two in Australia\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e, two from South Korea\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e and one study was performed in Italy\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Regarding the terminology of the intervention, seven studies referred to the intervention as \u0026apos;midline catheter\u0026apos;\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e while two studies used \u0026apos;extended dwell catheter\u0026apos;\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e and two studies used the term \u0026apos;long peripheral catheter\u0026rsquo;\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n \u003cp\u003eThe analysis encompassed eleven studies investigating the utilization of various devices for long peripheral catheter (LPC) placements. Among them, eight studies employed the Power Glide Pro\u0026trade; long peripheral catheter\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e, using different configurations. The catheters ranged from 22G and 8cm in length to 18G and 10cm in length. Additionally, two studies utilized the Powerwand\u0026reg; long peripheral catheter in both 20G and 6cm long versions and the 10cm-long version\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. One study took advantage of the Arrow\u0026reg; Endurance\u0026trade; long peripheral catheter, using catheters with dimensions ranging from 22G and 8 cm to 18G and 10cm\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n \u003cp\u003eAmong the studies included, nine reported the placement locations of the catheters\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. The basilic vein in the upper arm was cannulated in 36.8\u0026ndash;62.5% of the patients, while brachial vein cannulation in the upper arm was performed in 11.5\u0026ndash;62.4% of the cases. Additionally, the cephalic vein in the upper arm was cannulated in 0.9\u0026ndash;28% of the patients, revealing the diversity in vein selection based on the clinical context and patient anatomy.\u003c/p\u003e\n \u003cp\u003eEight studies provided data on first attempt success rates for catheter placements, ranging from the lowest reported rate of 72.7% to the highest rate of 93.9%\u003csup\u003e25,26,27,29,31,32,33,34\u003c/sup\u003e. Regarding the temporal demands associated with efficacious cannulation, elucidating perspectives emerge from three distinct investigative studies. The lowest recorded cannulation time was 8.66 minutes\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e, while the highest reported cannulation time was 45 minutes\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e in one study.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n \u003ch2\u003eCatheter-related outcomes\u003c/h2\u003e\n \u003cp\u003eA comprehensive summary of all catheter-related outcomes is presented in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003eDwell Time\u003c/h2\u003e\n \u003cp\u003eDwell times were reported in all studies, with median and mean values used for reporting. Recalculation to means was performed for six studies\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. Mean dwell times ranged from 2.92 (\u0026plusmn;\u0026thinsp;0.54)\u003csup\u003e25\u003c/sup\u003e to 17.1 (\u0026plusmn;\u0026thinsp;12.3) days\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Notably, 38\u0026ndash;85% of placed catheters remained in situ until completion of therapy\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n \u003cp\u003eA meta-analysis of three randomized studies was performed for dwell time to compare AST-LPCs to peripheral catheters (see Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. The mean difference was 1.98 (CI: 1.16\u0026ndash;2.80) in favor of the AST-LPC (p\u0026thinsp;\u0026lt;\u0026thinsp;0.00001). However, the heterogeneity was very high (I\u0026sup2; = 98%).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eCatheter-related infections\u003c/h2\u003e\n \u003cp\u003eEight studies provided data on catheter-related infections. Four studies reported no infections\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e, while the remaining studies documented infection rates ranging from 0.6\u0026ndash;10.2%\u003csup\u003e34,30,35,28\u003c/sup\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003eCatheter-related thrombosis\u003c/h2\u003e\n \u003cp\u003eEight studies provided data on catheter-related thrombosis rates ranging from 0.5\u0026ndash;15.4%\u003csup\u003e32,33,31,35,34,25,26,30\u003c/sup\u003e. One study reported a median time from insertion to deep venous thrombosis of 11 days (IQR 5\u0026ndash;14 days)\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. One study included a monitoring for pulmonary embolism, yet no events were recorded\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eInfiltration\u003c/h2\u003e\n \u003cp\u003eInfiltration rates were assessed across eight studies, with observed values ranging from 0% in a pilot RCT using a 10 cm long catheter to 24% in a RCT using a 6cm long catheter\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eOcclusion\u003c/h3\u003e\n\u003cp\u003eCatheter occlusion rates were reported in seven studies, ranging from 0.5\u0026ndash;10.2%\u003csup\u003e32,34,33,26,31,29,28\u003c/sup\u003e.\u003c/p\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003ePhlebitis\u003c/h2\u003e\n \u003cp\u003ePhlebitis rates were documented in four studies, with the lowest rate reported at 0.7%, and the highest at 9.8% \u003csup\u003e34,31,32,26\u003c/sup\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n \u003ch2\u003eOther Outcomes\u003c/h2\u003e\n \u003cp\u003eNine studies presented data regarding catheter-related dysfunction (e.g. Leaking, kinking, catheter migration, dislodgement). The prevalence of dysfunction ranged from 3.6\u0026ndash;15.7%\u003csup\u003e33,26,29,32,28,30,25,31\u003c/sup\u003e.\u003c/p\u003e\n \u003cp\u003eAccidental removal was also reported as a reason for premature removal of the catheter in four studies. This complication extended from 4.3\u0026ndash;16.2% \u003csup\u003e32,28, \u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n \u003cp\u003eOne study used five- and twenty-eight-days complication-free survival as an outcome variable and reported that 92.9% of catheters survived at five days, with 65.5% remaining functional until 28 days after placement\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n \u003cp\u003eLastly, one study followed up on nerve contact and arterial damage, but no such complications were observed\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this review, we aimed to comprehensively analyze the existing literature on catheter-related outcomes for long peripheral catheters placed using AST. To the best of our knowledge, this is the first review specifically focusing on this placement method within the adult DIVA population. Our findings indicate that the available literature is limited, with few randomized studies identified. Most studies were of low to moderate quality due to potential selection bias, retrospective designs and inconsistent data collection methodologies. Overall, reported complications were relatively low, with the highest complication rate being 24% for infiltration. Other complications, including catheter-related infections, thrombosis, occlusion, phlebitis, dysfunction, and accidental removal, were reported at rates below 15.7%.\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eInconsistency in terminology\u003c/h2\u003e \u003cp\u003eThis review underscores the inconsistency in terminology for catheters measuring 6\u0026ndash;15 cm in length. European guidelines advocate for the use of the term \u0026lsquo;long peripheral catheters\u0026rsquo; for such devices\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. However, this terminology has not been consistently adopted in scientific discourse, leading to continued ambiguity in catheter terminology. This may account for the reluctance to embrace the term \u0026lsquo;long peripheral catheter\u0026rsquo; in post-2021 non-European studies\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Establishing a global consensus on this terminology would enhance the clarity and uniformity of research in this domain and serve as a universally accepted reference for vascular access practitioners.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eDwell time\u003c/h2\u003e \u003cp\u003eMidline catheters (exceeding 15cm in length), with a terminal tip situated at the axilla, are recommended for the administration of peripherally compatible intravenous fluids and blood draws requiring a dwell time of four weeks or more\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Dwell times surpassing four weeks have also been observed in midline catheters, with Campagna et al. (2018) highlighting an impressive complication-free period of 273 days (median dwell time: 26 days, IQR: 12\u0026ndash;37 days)\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. Jeon et al. (2022) stood out by recording both five-day and 28-day complication-free durations\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. The overall mean dwell time in this systematic review was 8.91 days (SD: 4.46) resulting in an expected dwell time of 17.83 days (about 2 and a half weeks) in 95% of the cases when adding two times the standard deviation. This suggests that AST-LPCs are potentially suitable for infusing peripherally compatible solutions over an approximate two-week span. However, for peripheral intravenous medication therapies extending beyond 14 days, midline catheters of over 15cm should be the preferred choice. The first five days following insertion are vital for assessing complications potential early LPC failures, as this dwell time aligns with that of a short peripheral catheter\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. This proposition should be confirmed in further research using this type of devices.\u003c/p\u003e \u003cp\u003eThe intravenous length of the catheter plays a pivotal role in the longevity of ultrasound-guided peripheral catheters. A recent RCT propose a 2.75 cm benchmark of catheter length inside the vein for clinical use\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. This guideline favors the use of midline catheters, which, due to their termination in the axillary or subclavian vein, have a lower infiltration rate of just 0.6%, as reported in earlier studies\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e. Correspondingly, the 6 cm LPC that was included in this review had the lowest dwell time of all catheters with a mean of 2.92 (\u0026plusmn;\u0026thinsp;0.54) days and highest infiltration rate of 24%\u003csup\u003e25\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eCatheter-related complications\u003c/h2\u003e \u003cp\u003eIn this systematic analysis, catheter-related infections emerged as a predominant complication across evaluated studies, with the highest rate (10%) documented by one study using an aseptic non-touch technique combined with an exposed probe and sterile ultrasound gel\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Various guidelines emphasize protective measures such as probe covers, sterile single-use gel packets, and sterile gloves to minimize contamination risks during catheter placement during catheter placement\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e,41\u003c/sup\u003e. Notably, a surveillance study adapted CLABSI to Midline catheter-associated bloodstream infections (MLABSI). Instituting MLABSI rates as a quality metric could pave the way for more standardized reporting of this complication. Moreover, having such uniform data would enable rigorous follow-ups and comparative assessments across national and international medical centers, as indicated in previous research\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,42\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCatheter-related thrombosis was generally observed at a relatively low rate in this study; however, one study reported a higher incidence, with 15.4% of patients experiencing this complication\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. Of the total cases, 17 were classified as minor deep venous thrombosis (DVT), and one case involved a major DVT, which required catheter removal. The major DVT rate of 1.1% in this cohort aligns closely with, but is slightly lower than, the 1.4\u0026ndash;4.5% DVT rates reported in earlier studies involving midline catheters. \u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e,43\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e The review underscores the importance of clear flushing protocols to prevent occlusions, with Bundgaard Madsen et al. (2020) showing a maximum occlusion rate of 10.2%. Standardized flushing protocols including pulsatile flushing technique, incorporating 0.4s pauses in between flushes, with sufficient flushing volume (10ml in adults) as well as positive pressure application while disconnecting syringes is of major importance. Intra-and extraluminal flushing will be facilitated by using this technique but overdose of single push may cause mechanical endothelial injury and should therefore be avoided\u003csup\u003e44,45\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMidline catheters can mitigate phlebitis due to their placement in vessels with a larger diameter than lower arm veins, promoting hemodilution and reducing chemical phlebitis compared to peripheral catheters\u003csup\u003e46\u003c/sup\u003e. A recent meta-analysis revealed 1.52% phlebitis rates for midline catheters which was lower compared to the 3.41% for PICC catheters\u003csup\u003e47\u003c/sup\u003e. In this systematic review, Marsh et al.'s 2021 pilot RCT indicated 10% of phlebitis cases, with rates for AST-placed long peripheral catheters being half of standard peripheral catheters\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. It is worth noting that studies involving irritant medication infusions were excluded due to potential higher complication rates. However, a retrospective study, which encompassed 1086 patients receiving vancomycin (4mg/ml), indicated a mere 0.6% phlebitis rate. Given appropriate dilution, ultrasound-guided access, and the right device, it is inferred that vancomycin does not invariably necessitate a central venous catheter, supporting LPC placement\u003csup\u003e48\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eBased on this review we can conclude that given their extended length, specific placement location, and ultrasound-guided insertion, AST-LPCs are likely to offer prolonged dwell times in comparison to short peripheral catheters, potentially reducing prevalent complications. However, their anticipated dwell times remain shorter than midline catheters, underscoring the distinctions between these devices. In selecting the appropriate device for patients, healthcare professionals should employ standardized decision trees to differentiate between midline catheters and AST-LPCs. Future randomized studies should aim to contrast AST-LPCs with midline catheters in controlled environments to clarify their differences. The major advantage of the Accelerated Seldinger Technique (AST) lies in its ability to facilitate a one-handed, single-operator approach, which enhances procedural efficiency and operator control. Additionally, AST minimizes bleeding risks compared to the traditional Seldinger technique. The risk of contamination is also reduced, as is the potential for air or wire embolization, contributing to an overall safer and more streamlined vascular access procedure\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. Operators might experience a learning curve with this type of devices which can be encompassed by structured training programs and phantom training\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIt is imperative for policymakers to include monitoring of bloodstream infections associated with midline catheters (MLABSI) as a quality metric. While these catheters are growing in popularity as alternatives to central lines, thereby minimizing related complications, their routine follow-ups are potentially overlooked\u003csup\u003e49\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAdditionally, innovations in vascular access devices have brought forth the catheter-over-the-needle approach for LPCs. Although shorter in length (e.g., 6.4 cm) than AST-LPCs (8-10cm), these catheters still hold promise for extending dwell times in DIVA patients and curbing complications. Recent reports indicate median dwell times of 5.66 days for these devices\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. Yet, a direct comparison between them and either AST-LPCs or midline catheters is still pending.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis systematic review and meta-analysis is the first to specifically examine catheter-related outcomes of AST-placed long peripheral catheters (LPCs) in adult patients, addressing a critical gap in the literature. While a recent review\u003csup\u003e50\u003c/sup\u003e took a broader approach by comparing LPCs with midline catheters using multiple placement techniques, our study focuses exclusively on AST-placed LPCs. This offers a more targeted evaluation of this specific method. Our review adds four additional studies, including one randomized controlled trial and one retrospective cohort study, that were not part of prior analyses. Two of these studies were incorporated into our meta-analysis for dwell time. By not excluding studies based on methodological quality, we provide a comprehensive overview of the potential complications associated with AST-LPCs, which further clarifies the risks and benefits of this approach.\u003c/p\u003e \u003cp\u003eDespite the high heterogeneity observed in the included studies, the findings remain valuable in guiding practitioners to select the most appropriate device for each patient, which is crucial for vessel health preservation. With these recent advancements in our understanding of this topic, we can now refine hospital practices, design more precise clinical trials and enhance clinical decision-making to potentially improve patient outcomes.\u003c/p\u003e \u003cp\u003eThe strengths of this review include the use of a predefined protocol registered in the PROSPERO database, ensuring transparency and adherence to systematic review standards. Two researchers independently conducted the search, selection, data extraction, and quality assessment processes, which improves the reliability of our findings. To minimize selection bias, we conducted an extensive search across four databases spanning 20 years, identifying 1,017 potential studies. This comprehensive approach addresses a significant knowledge gap concerning AST-placed LPCs and offers valuable insights to vascular access specialists as they navigate catheter selection.\u003c/p\u003e \u003cp\u003eNevertheless, some limitations must be considered. Out of the eleven included studies, eight were retrospective, and ten were rated as lower quality, which may introduce bias and affect the overall reliability of our findings. The focus on adult patients limits the applicability of these results to pediatric populations, where catheter-related outcomes may differ significantly. These factors constrain the generalizability of our findings and highlight the need for caution in their interpretation.\u003c/p\u003e \u003cp\u003eTherefore, there is a pressing need for larger, high-quality, and randomized studies to validate and expand upon our findings and to provide more definitive guidance for clinical practice.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis systematic review and meta-analysis revealed a relatively low amount of catheter related complications for AST-placed LPC\u0026rsquo;s. For DIVA-patients, AST-placed LPCs might present a more enduring alternative to short peripheral catheters. For treatments extending over four weeks or more, conventional midline catheters might be superior to AST-LPCs in performance. Nonetheless, there is a pressing need for high-quality, randomized studies to further delineate the distinctions among AST-LPCs, midline catheters and the newer catheter-over-the-needle LPCs.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003eAuthor\u0026rsquo;s contributions\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWP \u0026amp; BVD: Conception, design, acquisition, analysis, interpretation of data, writing the manuscript\u003c/p\u003e\n\u003cp\u003eAS, DV, KB, TT: substantial revision of the review and approval of the submitted version.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStatements and Declarations\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article\u003c/p\u003e\n\u003cp\u003eEthical considerations\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eFunding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe author(s) received no financial support for the research, authorship, and/or publication of this article.\u003c/p\u003e\n\u003cp\u003eSupplemental material\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSupplemental material for this article is available online.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMermel LA (2017) Short-term peripheral venous catheter\u0026ndash;related bloodstream infections: a systematic review. Clin Infect Dis 65:1757\u0026ndash;1762\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHelm RE, Klausner JD, Klemperer JD, Flint LM, Huang E (2015) Accepted but unacceptable: peripheral IV catheter failure. J Infus Nurs 38:189\u0026ndash;203\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRay-Barruel G, Xu H, Marsh N, Cooke M, Rickard CM (2019) Effectiveness of insertion and maintenance bundles in preventing peripheral intravenous catheter-related complications and bloodstream infection in hospital patients: a systematic review. Infect Dis Health 24:152\u0026ndash;168\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWei T, Li XY, Yue ZP et al (2019) Catheter dwell time and risk of catheter failure in adult patients with peripheral venous catheters. J Clin Nurs 28:4488\u0026ndash;4495\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRickard CM, Marsh N, Webster J et al (2018) Dressings and securements for the prevention of peripheral intravenous catheter failure in adults (SAVE): a pragmatic, randomised controlled, superiority trial. Lancet 392:419\u0026ndash;430\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlatt V, Osenkarski S (2018) Improving vascular access outcomes and enhancing practice. J Infus Nurs 41:375\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRickard CM, Webster J, Wallis MC et al (2012) Routine versus clinically indicated replacement of peripheral intravenous catheters: a randomised controlled equivalence trial. Lancet 380:1066\u0026ndash;1074\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWebster J, Clarke S, Paterson D et al (2008) Routine care of peripheral intravenous catheters versus clinically indicated replacement: randomised controlled trial. \u003cem\u003eBMJ\u003c/em\u003e ; 337\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHawes ML (2007) A proactive approach to combating venous depletion in the hospital setting. J Infus Nurs 30:33\u0026ndash;44\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSabri A, Szalas J, Holmes KS et al (2013) Failed attempts and improvement strategies in peripheral intravenous catheterization. Biomed Mater Eng 23:93\u0026ndash;108\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Loon FH, van Hooff LW, de Boer HD et al (2019) The modified A-DIVA scale as a predictive tool for prospective identification of adult patients at risk of a difficult intravenous access: a multicenter validation study. 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BMC Med Res Methodol 5:1\u0026ndash;10\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReview Manager (RevMan) Version 5.4. The Cochrane Collaboration, Available at revman.cochrane.org\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBahl A, Hang B, Brackney A et al (2019) Standard long IV catheters versus extended dwell catheters: a randomized comparison of ultrasound-guided catheter survival. Am J Emerg Med 37:715\u0026ndash;721\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarsh N, Larsen E, O'Brien C et al (2021) Midline pilot randomised controlled trial: Managing peripheral intravenous devices among adult hospital patients with limited vascular access or prolonged therapy trial. Infect Dis Health 26:S6\u0026ndash;7\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFabiani A, Santoro M, Sanson G (2023) The catheter-to-vein ratio at the tip level, not the catheter type, as a risk factor for a catheter failure. A retrospective comparative study of polyurethane midline and long peripheral catheters. Heart Lung 60:39\u0026ndash;44\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBundgaard Madsen E, Sloth E, Skov Illum B, Juhl-Olsen P (2020) The clinical performance of midline catheters\u0026mdash;An observational study. Acta Anaesthesiol Scand 64:394\u0026ndash;399\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFung CM, Stayer DR, Terrasi JJ et al (2021) Extended dwell and standard ultrasound guided peripheral intravenous catheters: Comparison of durability and reliability. Am J Emerg Med 47:267\u0026ndash;273\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJeon MH, Kim CS, Han KD, Kim MJ (2022) Efficacy and safety of midline catheters with integrated wire accelerated Seldinger technique. Vasc Spec Int ; 38\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJohnson A, Gupta A, Feierabend T et al (2023) Midline catheters: A 3-year experience at a veterans administration medical center. Am J Infect Control 51:563\u0026ndash;566\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones P (2023) Implementation of a midline catheter service in a regional setting. Br J Nurs 32:S38\u0026ndash;42\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee MO, Lee SK, Song YG (2023) Midline Catheters in the Operating Room. Niger J Clin Pract 26:1097\u0026ndash;1100\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel SA, Araujo T, Rodriguez LP et al (2019) Long peripheral catheters: a retrospective review of major complications. J Hosp Med 14:758\u0026ndash;760\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNielsen EB, Antonsen L, Mensel C et al (2021) The efficacy of midline catheters\u0026mdash;a prospective, randomized, active-controlled study. Int J Infect Dis 102:220\u0026ndash;225\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCampagna S, Gonella S, Zerla PA et al (2018) The risk of adverse events related to extended-dwell peripheral intravenous access. Infect Control Hosp Epidemiol 39:875\u0026ndash;877\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBahl A, Hijazi M, Chen NW et al (2020) Ultralong versus standard long peripheral intravenous catheters: a randomized controlled trial of ultrasonographically guided catheter survival. Ann Emerg Med 76:134\u0026ndash;142\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChopra V, Kaatz S, Swaminathan L et al (2019) Variation in use and outcomes related to midline catheters: results from a multicentre pilot study. BMJ Qual Saf 28:714\u0026ndash;720\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGorski LA, Hadaway L, Hagle ME et al (2021) Infusion therapy standards of practice. J Infus Nurs 44:S1\u0026ndash;224\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoureau N, Gregory EG (2020) Survey of ultrasound-guided peripheral intravenous practices: a report of supply usage and variability between clinical roles and departments. Br J Nurs 29:S30\u0026ndash;S38\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThompson J, Garrett JH (2018) Transducer disinfection for evaluation and insertion of peripheral and central catheters for vascular access teams and clinicians. J Assoc Vasc Access 23:141\u0026ndash;146\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDawson RB, Moureau NL (2013) Midline catheters: an essential tool in CLABSI reduction. Infect Control Today 3:1\u0026ndash;9\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLisova K, Hromadkova J, Pavelkov\u0026aacute; K et al (2018) The incidence of symptomatic upper limb venous thrombosis associated with midline catheter: prospective observation. J Vasc Access 19:492\u0026ndash;495\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGoossens GA (2015) Flushing and locking of venous catheters: available evidence and evidence deficit. \u003cem\u003eNurs Res Pract\u003c/em\u003e ; 2015: 985686\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhu L, Liu H, Wang R et al (2020) Mechanism of pulsatile flushing technique for saline injection via a peripheral intravenous catheter. Clin Biomech 80:105103\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAdams DZ, Little A, Vinsant C, Khandelwal S (2016) The midline catheter: a clinical review. J Emerg Med 51:252\u0026ndash;258\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLu H, Yang Q, Tian B et al (2022) A meta-analysis of the comparison of phlebitis between midline catheters and peripherally inserted central catheters in infusion therapy. Int J Nurs Pract 28:e12976\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaparas JV, Hung HS (2017) Vancomycin administration through a novel midline catheter: summary of a 5-year, 1086-patient experience in an urban community hospital. J Assoc Vasc Access 22:38\u0026ndash;41\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHogle NJ, Balzer KM, Ross BG et al (2020) A comparison of the incidence of midline catheter\u0026ndash;associated bloodstream infections to that of central line\u0026ndash;associated bloodstream infections in 5 acute care hospitals. Am J Infect Control 48:1108\u0026ndash;1110\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFabiani A, Aversana N, Santoro M, Sanson G (2024) Complications associated to midline-and long peripheral catheters in adults. Systematic review of literature and proposal for a standardized model for data collection. Thromb Res ; 50\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Universitair Ziekenhuis Brussel","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Accelerated Seldinger Technique, Indwelling time, Infection, Occlusion, Phlebitis, Long peripheral catheter, Systematic review, Nursing, Vascular access","lastPublishedDoi":"10.21203/rs.3.rs-5737761/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5737761/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eManaging intravenous therapy in patients with difficult intravenous access (DIVA) often requires the use of midline catheters (MCs) or long peripheral catheters (LPCs). This study aimed to review and meta-analyze catheter-related outcomes of LPCs inserted using the Accelerated Seldinger Technique (AST) in adult DIVA patients, focusing on dwell time, catheter-related infections, thrombosis, infiltration, occlusion, phlebitis and other outcomes. A systematic review was conducted on quantitative studies from 2000 to 2023, sourced from databases including CINAHL, Cochrane Library, Google Scholar and PubMed, to identify studies on adult DIVA patients requiring AST-LPCs. The review adhered to PRISMA guidelines, and the Quality Assessment Tool for Quantitative Studies was used to ensure rigorous evaluation. Of 1017 records initially reviewed, 11 studies were included in the final analysis. The mean dwell time for LPCs ranged from 2.92 (\u0026plusmn;\u0026thinsp;0.54) to 17.1 (\u0026plusmn;\u0026thinsp;12.3) days. A meta-analysis showed a significant mean difference in dwell time of 1.98 days (\u0026plusmn;\u0026thinsp;1.16 to 2.80) in favor of LPCs over short peripheral catheters (p\u0026thinsp;\u0026lt;\u0026thinsp;0.00001). Reported complications included infiltration (up to 24%), dysfunction (up to 15.7%), thrombosis (up to 15.4%), catheter-related infections (up to 10.2%), occlusion (up to 10.2%) and phlebitis (up to 9.8%). The findings suggest that AST-LPCs may offer greater durability than short peripheral catheters in DIVA patients. While MCs may be more effective for therapies exceeding four weeks, they involve higher procedural complexities. This review highlights the need for high-quality randomized studies comparing AST-LPCs, MCs, and newer catheter-over-needle LPCs to better inform vascular access specialists in managing DIVA patients.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eProspero ID\u003c/span\u003e: CRD42023425513\u003c/p\u003e","manuscriptTitle":"Impact of Accelerated Seldinger Technique long peripheral catheters on catheter related outcomes: a systematic review and meta-analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-18 13:25:08","doi":"10.21203/rs.3.rs-5737761/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f145977e-2452-4b78-851f-449ae70642c3","owner":[],"postedDate":"February 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":44233610,"name":"Nursing"},{"id":44233611,"name":"Anesthesiology \u0026 Pain Medicine"},{"id":44233612,"name":"Critical Care \u0026 Emergency Medicine"}],"tags":[],"updatedAt":"2025-02-18T13:25:08+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-18 13:25:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5737761","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5737761","identity":"rs-5737761","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}